Provider Demographics
NPI:1659608073
Name:CORNELIUS, KAMESHNI (PA)
Entity Type:Individual
Prefix:
First Name:KAMESHNI
Middle Name:
Last Name:CORNELIUS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 KETTLAND KRING
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-7808
Mailing Address - Country:US
Mailing Address - Phone:641-777-0289
Mailing Address - Fax:641-621-7969
Practice Address - Street 1:1210 E VERMEER RD
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-7660
Practice Address - Country:US
Practice Address - Phone:641-621-7670
Practice Address - Fax:641-621-7969
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002002363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1659608073OtherNPI
IA002002OtherIOWA LICENSE
IA002002OtherIOWA LICENSE